Day 12 &13: "Our regular midwife Grace"

Yesterday was another day at the office, and I am continuing to gain little bits of knowledge. However, I have also gotten to the point where I can almost predict what the midwife will say next because of everything I have learned so far. In fact, the joke of the day was when Jon was introducing Erin and me to a patient, she said, "This is our midwife student Erin, and this is our regular midwife Grace." We all burst out laughing. The rest of the day I was called the "regular midwife."

After being at the office until 3:00, I came home and made significant progress on my final project, which I am excited about! It is coming together really nicely. However, the highlight of my day yesterday was reading the 50-page story that my mom wrote of my birth. After having four births in a hospital, my mom decided to have me at home with a midwife. The most moving part of the story for me was how my older brothers reacted to it. My brother Deke, who was four at the time, loved to massage my mom's belly and feel when I kicked in response. Because he did this so often, he learned how to tell what position I was in. I was breeched until 34 weeks, and one night when he was massaging, he realized that I was finally head down, and shouted, "The baby has turned!" When he was putting me in my first outfit a couple hours after I was born, he said to me, "Grace, you know these hands." My second oldest brother's response to the birth was, "Can we have ALL of our babies this way?!" Because I was born at home with a midwife, I was able to connect with my brothers from the very beginning in a way that not very many people are able to.  

The midwife Kathy Berry teaching Owen (almost two years old) how to listen for the heartbeat

Today was my last day at the office, which I spent with my mentor Irma. Not only am I sad to be done there, the nurses and midwives were sad it was my last day, too. Erin especially didn't want me to leave because I was her "student buddy." Everyone there is very nice, and they all said they want to see my final project when it is complete.

Erin and I

Carrie, one of the nurses, and I

My last day at the office was cut a little short because the rest of the time I went to interview the midwife who birthed me! I wanted to get another perspective on midwifery since she did home births and gain as much knowledge as I could to accomplish my last two goals. As a reminder, my fourth goal is to research, analyze, and compare statistics of infant mortality rates in other countries around the world versus the United States and understand some of the causes, and my fifth goal is to better understand the differences in philosophies between physicians and midwives. She was saying that in many other countries, especially in Europe, midwifery is the main healthcare for pregnant women, and physicians are the backups if there are complications. The problem with the United States and why our cesarean section rate is so high is that physicians, who are surgeons, are mostly in charge, and the training between midwives and physicians is very different. Kathy is not a certified midwife, and instead she learned by spending all of her time with other midwives and never went to nursing school to become a nurse midwife. The philosophies of midwives such as herself is that they are confident that the mom can give birth on her own, and their job is to educate and support her so that the mom knows what is best for herself, and she can naturally give birth. In return, when a mom is so in touch her body, she knows when something is truly wrong. For example, Kathy told me a story of a baby who was breeched towards the very end of pregnancy, and she tried to do an external version, but every time she tried, the baby's heartbeat would drop way down, and the mom knew something was wrong, so she ended up going to the hospital and getting a cesarean section. The cord was wrapped four times around the baby's neck. The difference was that instead of a doctor telling the mom something was wrong, she could sense it on her own. 

I really enjoyed talking to Kathy and hearing her perspective, and it definitely helped me gain a greater understanding of my last two goals. Tomorrow I am going to finish up researching about my fourth and fifth goal and putting my presentation together for the 11th! 

Day 11: Midwife Grace

Today was another normal day full of appointments with Kim and Jon, but today I got to do more than I have in the past. Kim asked me if I would use the doppler and find the heartbeat with most of her OB patients! She watched me as I would squirt some gel on the monitor, turn it on, place the monitor on the patient's belly, move it around slightly until hearing the "swish-swish" of the baby's heartbeat, then recording the BPM. One of the babies had a heart murmur, so every fifth beat was irregular, which could be heard on the doppler. The irregular beats sounded higher-pitched and sometimes louder than the other beats.

I am still continuing to gain little bits of knowledge with a lot of the patients that come in. One of the OB patients who was only several weeks pregnant previously had a miscarriage, a stillborn, then a healthy baby before her current pregnancy. However, she was wondering how long it would be safe for her to breastfeed her other child during this pregnancy. Because of her past mishaps, Jon said that they would need to check the length of her cervix because breastfeeding can cause more contractions. This would be problematic with a short cervix because it could cause a premature delivery. I didn't know that breastfeeding while pregnant could be such a risk in a situation like that.

Another one of the patients was a confirmation of pregnancy, and I learned more about the human chorionic gonadotropin (hCG) hormone, which is a hormone made by the placenta and released to confirm the pregnancy through a blood or urine test. The amount of hCG should double every two days until 8-11 weeks, which is when the levels peak then decline. An ultrasound can be done once the hCG level reaches 2,000 units, but they can approach 25,000 units or higher by the peak.

I have been coming up with ideas for my final presentation, and I have started to work on the very beginning of it. I am excited to show everyone what I have seen and learned in these several weeks.

Day 9 & 10: The Midwife Life

Now that I am nearing the end of my independent study, I have gotten a good chance to see what this model of midwifery is like and can begin to reflect on my third goal.

The biggest thing I have noticed (which the midwives talk about a lot) is the number of hours the midwives work every week–usually 50 or more. This often includes several nights a week when they don't get any sleep or very little and instead spend that time at the hospital. I have gotten a little taste of what this is like. The few days that I was on call, I jumped at every little noise my phone made, waiting for something to happen every second. While this was fun for a couple days as I was anticipating a miraculous experience, I think it would be a very difficult lifestyle to live every week, especially for someone who has a family of her own. The payoff for working as much as the midwives do is amazing–getting to bring life into the world–but it is a huge commitment for someone to make.

Another thing that I have noticed about this style of midwifery is that the vast majority of the time is spent with the mother throughout her nine months of pregnancy, and only a very small amount of time is with a baby–at the birth and a couple appointments during postpartum. However, I have found that the most rewarding parts of this experience for me were the times with the babies. For example, the highlight of my day at the office the other day was getting to hold a little three-week old baby, and the main reason I loved observing a birth so much was seeing the tiny infant during its very first moments of life outside the womb.

Although I have greatly enjoyed–and continue to enjoy–my time as a midwifery intern, I have realized that a job that would be the most rewarding for me would be one that works mostly and more directly with the babies, since that is what I have found lights me up the most and really makes me overjoyed. This being said, I am very glad that I am having this experience and exploring what I want in a future career because it is helping me narrow down my options and become more specific in what I want to study. In addition, this experience is teaching me so much about women's health in general, which is a very good thing for me to learn at an early age.

Day 8: 7 Pounds, 8 Ounces

It finally happened! I went to the hospital just after noon and rode the elevator all the way up to the 7th floor. Going to a hospital alone I thought would be a bit daunting, but it wasn't bad at all! I called Jon as soon as I got there, and she met me in the waiting area.

The mom was induced early this morning, and her water broke just as I was getting to the hospital. She did end up getting an epidural, so I had to sit in the waiting room for about 15 minutes while she had that done, then I went into the room with Jon to check up on her and see how dilated she was. I could tell watching the dad as he sat on the coach with his hands on top of his head looking down that he was nervous and wanted it all to be over. While we were in the room with her, Erin (the midwifery student) arrived and started helping Jon. After that, the mom wanted to get some rest and take a nap if she could, so we left her and her husband alone.

It was very cool being with Jon and Erin because I got a behind the scenes look at the hospital. Jon told me all of the codes for the nurses' offices and took me through all of the back doors, the ones that say, "This is not an entrance." While the mom was resting, I decided to get some reading done, so Jon took my up to the 8th floor where the midwives have a couple rooms with beds where they sometimes sleep over night. I stayed in there reading until about 4:20 since nothing major was happening with the baby yet, then Jon and Erin came back up to relax for a bit. At about 4:35, Jon said that she had a little voice in her head telling her it was time to check on the mom, so I went down with her, not expecting anything major to happen anytime soon. I was so wrong.

Once we were in the room, Jon checked her and said that she was fully ready to deliver. Before I knew it, she was asking the mom to push. Jon was on one side, and Erin was on the other. I could see the baby come so far with every push. Within five minutes of entering the room, I could see the baby's head, and I couldn't believe it was happening that fast! The mom kept pushing, and as soon as the shoulders were clear no more than two minutes later, the baby came out so fast Erin and Jon barely caught her–a girl!. The nurse stated that their baby was born at 4:48. They immediately put her up on the mom's chest. The smile on the dad's face was so big, and I could tell he was extremely happy and relieved.

The mom asked me if I would take pictures as the dad cut the cord, and I did so gladly. One of the nurses then took the baby to be weighed and wrapped in a blanket: 7 pounds, 8 ounces. Meanwhile, Jon and Erin worked to get the placenta out. Once it was out, Jon examined it and determined it was extremely healthy. She showed me all of the different parts of it and explained the corresponding functions. Although many people would probably see it as gross, I thought it was extremely fascinating. I asked permission to take a few pictures of it, and she didn't mind. Here is a picture of the fetal side of the placenta with the umbilical cord:

The mom had a slight (first degree) tear because of how fast the delivery went, so I watched as Erin put in two dissolvable stitches. They cleaned her up, and I helped by bringing wet towels, then the dad brought the baby back to her so she could nurse it for the first time. I thanked the mom for being so open and willing with everything she let me see, and she said she was very glad I could be there.

I have now accomplished my second goal! This was the goal I was most worried I wouldn't accomplish but also the most excited about if it did happen, and it was every bit as exciting as I thought it would be.

Day 7: No Baby Yet

Apparently I am starting to look like I fit in here because today I had a patient stop and ask me a medically-related question. Although I was flattered, I pointed her in the direction of one of the nurses.

Last week I learned a lot in just a few short days, but I was wondering if at some point most of the information would be a repeat of what I have already learned. However, I am continuing to see, hear, and experience new things every day. This morning I got to see an ultrasound for the first time. The patient was 16 weeks, but Irma tried to find the baby's heartbeat for about five minutes without success, so she decided to bring the ultrasound machine in. I was able to see the tiny heart flapping back and forth on the screen. This picture points out what a baby's heart looks like on an ultrasound:

One of my highlights of today was holding a tiny three-week-old baby while the mom went to get on a scale. So cute!

After waiting on call for three days this weekend, "my" mom still hadn't gone into labor! Today she is 41 weeks, and I have heard from Irma that she is going to the hospital tonight! I will probably be up for most of the night at the hospital, but I am very excited! She came in to the office today to get a biophysical profile (BPP), which I got to see for the first time. It was done to make sure that the baby is still healthy being a week overdue. BPPs check for four things: the amound of amniotic fluid, fetal heartrate and breathing, fetal tone (the ability to flex and use muscles), and fetal movement. Nothing looked worrisome in her BPP, but she is getting worried and doubting her body's ability since with her last birth, her water broke but she never started contracting, so she had to get induced. She is afraid that something like that will happen again, especially since she is already a week overdue, so she got her membranes stripped today to realease the prostaglandins and get more regular and frequent contractions.

Get ready for tomorrow's blog post!

Day 6: I found a mom!

Today was the first time I saw a repeat patient, and in fact she was the very first patient I saw on Tuesday. She is now four days overdue and came back for another NST since it has been three days since her last one. The NST showed that she was having regular contractions every three to five minutes, but they weren't very strong yet, so she is waiting to go to the hospital. During her 20-minute long NST, she was asking me where I go to school and what exactly I am doing with the midwives. I told her all about what I get to do during my intensive, and she sounded very interested by it. The most exciting part is that I asked her if I would be able to attend her birth, and right away she said yes! It will probably happen either tonight or tomorrow, so I am very excited. Jon is on call all weekend, so she will most likely be the one delivering.

I definitely feel like I have accomplished my first goal as of today. Even if something happens and I don't get to see her birth, I got to know her well enough and she got to know me well enough that she felt comfortable saying yes right away when I asked. She not only said yes, but she responded, "Birth is such an amazing thing, and I would really love for you to get to see it." I had a feeling when I met her on Tuesday that she might be the one I would ask if I didn't run out of time.

I set my phone on the loudest, most obnoxious ringtone so that if I get the call in the middle of the night, I will be sure to wake up and get to the hospital!

Day 5: Diabetes and Pregnancy

Today was another very early morning with appointments starting at 7:30 a.m. again. I was with the last of the three midwives, Jonalea, or Jon for short. She was very good about explaining as much as she could to me and always asking if I had any questions. There was also a new RN who started at the office today who will be with the Mercy Midwives for about six months and is working towards graduating from the Frontier Nursing University to become a midwife.

The first patient of the day has two days until her due date, but she is a diabetic (insulin-dependent, not gestational), so it is recommended that the baby be born by the due date or else it runs the risk of getting too big. This is from extra sugar from the mom that gets passed through the placenta to the baby, whereas normally it would exit the body in the urine. She had an NST done to make sure everything was normal, and Jon explained what exactly they look for in the graph to classify the baby as healthy. It is a 20-minute long test, and there should be quite a bit of variability in the heart rate with an average of around 130 BPM. Jon also looks for at least three spikes to around 150 BPM for about 15 seconds within the 20 minutes. The NST also monitors contractions, and the graph showed that she was having small regular contractions every five to seven minutes. Here is an example of what an NST graph looks like:

The top line shows the heart rate, and as can be seen, there are the three spikes that last for a duration of 15 seconds or more, which is a very good sign. There are no major dips, which is also a good sign because it shows that the baby is getting enough oxygen from the placenta. The bottom line records any contractions, but there doesn't seem to be anything significant in this test. 

Jon also explained the Bishop score to me, which is a score that measures the softness of the cervix, how far down the cervix is, and how dialated it is. The patient got a score of eight, which is the most favorable score and shows that she is very close to being in labor. If she does not go into labor tonight, the plan is for her to go to the hospital tomorrow at 9:00 to get induced because of her diabetes and her approaching due date. The Mercy Midwives generally like to stay away from inductions unless medically necessary, but this is a situation in which it could become medically necessary because of the risk that comes with exceeding the due date.

I was able to get a hold of the Mercy Midwives' statistics for births today. Although they are from 2000-2001, I was told that their numbers haven't changed much in 15 years.

The area-wide rate for cesarean sections has gone up to about 33% since 2001, but the Mercy Midwives' rate has stayed very similar. 

Irma came into the office today for a little bit even though she was not seeing patients, and she said that she was at the hospital most of the night delivering the baby that was due yesterday and had come in for an NST! She said that it was a very healthy, beautiful baby. We are still working on finding a mom who will allow me to be at her birth, but I'm learning that there will be no shortage of births in the next two weeks, so there is plenty of time at this point.